Health inspection·May 1, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm asthma, and lobar PNA (pneumonia). (Date Initiated: 03/24/2025, revised 4/15/25) Goals/interventions in place and appropriate. - Resident is a an unsafe smoker as evidenced by smoking evaluation. (Created 03/26/2025, revised 03/26/2025) Goals/interventions in place and appropriate. Residents Affected - Few - Resident has impaired cognitive function/impaired thought process. (Created 04/01/2025, revised 04/01/2025). Goals/interventions in place and appropriate. The entire care plan was reviewed and there was no evidence of the resident having been care planned for self-administration of medications or treatments. On 05/01/25 at 11:44 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. When she was asked if residents were permitted to give themselves any kind of medication on their own, she replied, No. She was asked if residents were permitted to keep medications in their rooms or in their possession. She stated, No. She was asked what she should do if she observed medications in the resident's room or in their possession. She replied, Go and get my nurse or Unit Manager immediately. On 05/01/25 at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. When she was asked what the facility's protocol was for a resident who wanted to self-administer their own medications, she replied, They don't allow them to administer their own medicine. She was asked of there were any residents on her assignment who self-administered medications. She stated, No. She was asked if residents were permitted to give themselves any kind of medication on their own. She stated, No. She was asked if residents were permitted to keep medication in their room or in their possession. She stated, No, like on admission we give medications to the family to take back home so the residents wont have them. She was asked what she should do if she observed medications in the resident's room or in their possession. She stated, I would get it. They might be a little upset with me, but I would get them because its not supposed to be there. Then I would call the family and notify the MD (physician). On 05/01/25 at 2:00 PM, an interview was conducted with CNA C. She was asked if she had observed Resident #108 with her inhaler in her room at the bedside or in her purse. CNA C replied, Yes. She was asked if she had observed Resident #108 using an inhaler on her own, and she replied, No. She was asked if the facility provided any guidance/training/education on how to respond if you observe medications in the resident's room. She stated, No, but I know how to handle that; let the nurse know. She was asked if she had reported the resident having the inhaler in her possession. She stated, No, I have not reported the inhaler to the nurse, but she had to have seen it herself, she could not miss it, it was in there today in plain site. A review of the facility's policy and procedure titled Self-Administration of Medications (SHCRC30004.01B, revised 8/2023), revealed: Purpose: To allow the resident and or legal representative the right to self-administer medication (SAM) when it has been deemed by the interdisciplinary team (IDT) that it is clinically appropriate. A resident may only self-administer medications after the IDT has determined which medications may be self-administered. Document the self-administration of medication on the resident's comprehensive care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105710 If continuation sheet Page 2 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Nursing and Rehab Center 4134 Dunn Avenue Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm plan. [NAME] medication administration records to identify individual medicines that are self-administered by each resident. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105710 If continuation sheet Page 3 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Nursing and Rehab Center 4134 Dunn Avenue Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interviews, and a review of the facility's policies and procedures, the facility failed to provide respiratory care consistent with professional standards of practice for one (Resident #33) of four residents reviewed for oxygen administration. Resident #33 was receiving oxygen without a physician's order. Residents Affected - Few The findings include: On 04/29/25 at 11:13 AM, an interview was attempted with Resident #33. He offered no verbal response to interview questions, and instead covered his head. Oxygen was observed infusing at 3.5 L/min (liters per minute) via nasal cannula (NC). A review of Resident #33's medical record revealed an admission date of 3/26/2013 and diagnoses including heart failure, COPD (chronic obstructive pulmonary disease) and acute and chronic respiratory failure with hypoxia. A review of the resident's active physician's orders revealed no orders for oxygen therapy. A review of the Quarterly MDS (minimum data set) assessment, dated 4/16/25, revealed a BIMS (brief interview for mental status) score of 15 out of 15 possible points, indicating intact cognition. The resident was independent with eating. He was dependent on staff for toileting and transfer tasks, and required substantial/maximal assistance with bed mobility. A review of the active Care Plan revealed the following focus areas: - [Resident #33] is at risk for impaired gas exchange related to COPD and chronic respiratory failure. (created 7/20/20, revised 3/10/25). Goal: Resident will have decreased risk of complications related to impaired gas exchange through the review date. Interventions: Oxygen as ordered. Clean concentrator/filters as ordered. Change oxygen tubing as ordered. - [Resident #33] requires assistance with ADLs related to limited mobility and muscle weakness secondary to CHF (congestive heart failure), COPD, AFIB (atrial fibrillation), urine retention, chronic respiratory failure, neuromuscular dysfunction of bladder, depression, obesity, anemia, hypokalemia, dorsalgia, sleep apnea, diabetes mellitus, right foot drop, obstructive/reflux uropathy, ADHD (attention deficit hyperactive disorder), hydrocephalus, and HTN (hypertension). Goals/interventions in place and appropriate. A review of the resident's progress notes revealed a note dated 4/11/2025 at 20:35 (8:35 p.m.) that noted the resident was evaluated by the provider for COPD management. The patient is currently on a complicated pulmonary regimen to consist of Albuterol as needed. The patient remains on intermittent oxygen. Patient does report at times some shortness of breath with exertion. On 05/01/25 at 11:39 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. She was asked if the facility provided any training/education for how to care for a resident who received oxygen therapy. She stated, No, because it's considered medicine so it's taken care of by the nurse. She was asked to describe the care she provided for a resident who was receiving oxygen. She stated, We just make sure that they keep it in their nose and that the tank is full. Anything else, you notify the nurse. For instance, if the tubing looks dirty or clogged or if it's on the floor, or if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105710 If continuation sheet Page 4 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Nursing and Rehab Center 4134 Dunn Avenue Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the tank is empty. She was asked if she had ever been required to change the oxygen flow rate settings. She stated, No. She was asked what she would do if the resident became short of breath. She stated, Notify the nurse or the Unit Manager. On 05/01/25 at 1:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. She was asked if the facility provided any training/education for how to care for a resident who received oxygen therapy. She stated, Yes. She was asked to describe the care she provided for for a resident who was receiving oxygen therapy. She stated, We monitor their saturations, provide the breathing medication, and if they have orders for oxygen we make sure the oxygen is set at right level and make sure the room is comfortable. She was asked who was responsible for changing oxygen flow rate settings. She stated, Yes, only the nurse is supposed to change the settings. She was asked what she would do if the resident became short of breath. She stated, First make sure the head is elevated, monitor the oxygen saturations, give the medication, and I may need to increase the oxygen level. When they get stable, I reach out to the medical doctor. She was asked if Resident #33 used oxygen. She stated, Yes, at times. She was asked how often he used it. She stated, I think he uses it on a daily basis but he medicates himself. He takes it on and off. She was asked how she determined the resident's oxygen flow rate. She stated, Whatever the doctor orders. She was asked to access the resident's orders in the EMR (electronic medical record) and confirm how many liters the doctor ordered for Resident #33. She confirmed that the resident did use oxygen daily and did not have an order for it. On 05/01/25 at 3:44 PM, a policy/procedure for oxygen administration was requested. The Regional Nurse Consultant stated, We don't have an oxygen policy. A review of the facility's Procedural Guideline (SHCEDU0001.11M, effective: 1/2023, updated: 6/28/2024) for Physician's Orders revealed: A new order should include: date of order, resident name, identification number, date of birth , physician's/prescriber's name and pertinent ancillary instructions, reason for use, stop order date, as appropriate, and administration parameters, if applicable. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105710 If continuation sheet Page 5 of 5